I both enjoyed and admired Paul Kalanithi’s When Breath Becomes Air, which is why I posted a bog about it on the BMJ website:
I also took so many quotes from from the book, many of them used in my blog, but they are all below.
I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them.
It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action.
Descriptions like Nuland’s convinced me that such things could be known only face-to-face. I was pursuing medicine to bear witness to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.
What had not changed, though, was the heroic spirit of responsibility amid blood and failure. This struck me as the true image of a doctor.
And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise. Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases.
to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the impact of any major life event. At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability— or your mother’s— to talk for a few extra months of mute life?
I was compelled by neurosurgery, with its unforgiving call to perfection; like the ancient Greek concept arete, I thought, virtue required moral, emotional, mental, and physical excellence. Neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death.
Perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.
My first day in the hospital, the chief resident said to me, “Neurosurgery residents aren’t just the best surgeons— we’re the best doctors in the hospital. That’s your goal. Make us proud.”
At moments, the weight of it all became palpable. It was in the air, the stress and misery. Normally, you breathed it in, without noticing it. But some days, like a humid muggy day, it had a suffocating weight of its own. Some days, this is how it felt when I was in the hospital: trapped in an endless jungle summer, wet with sweat, the rain of tears of the families of the dying pouring down.
Learning to judge whose lives could be saved, whose couldn’t be, and whose shouldn’t be requires an unattainable prognostic ability. I made mistakes. Rushing a patient to the OR to save only enough brain that his heart beats but he can never speak, he eats through a tube, and he is condemned to an existence he would never want … I came to see this as a more egregious failure than the patient dying. The twilight existence of unconscious metabolism becomes an unbearable burden, usually left to an institution, where the family, unable to attain closure, visits with increasing rarity, until the inevitable fatal bedsore or pneumonia sets in.
I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles … surely a kind of transcendence would be found there?
In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun.
I observed a lot of suffering; worse, I became inured to it.
I wondered if, in my brief time as a physician, I had made more moral slides than strides.
I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease— and utterly missing the larger human significance. (“ Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from.”)
As a resident, my highest ideal was not saving lives— everyone dies eventually— but guiding a patient or family to an understanding of death or illness.
When there’s no place for the scalpel, words are the surgeon’s only tool.
In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador.
I don’t think I ever spent a minute of any day wondering why I did this work, or whether it was worth it. The call to protect life— and not merely life but another’s identity; it is perhaps not too much to say another’s soul— was obvious in its sacredness.
How little do doctors understand the hells through which we put patients.
If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed. Two hours could feel like a minute.
After someone suffers a head trauma or a stroke, the destruction of these areas often restrains the surgeon’s impulse to save a life: What kind of life exists without language?
It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it. Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible— or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination.
“He, uh— he apparently had a difficult complication, and his patient died. Last night he climbed onto the roof of a building and jumped off. I don’t really know anything else.”
But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
Severe illness wasn’t life-altering, it was life-shattering. It felt less like an epiphany— a piercing burst of light, illuminating What Really Matters— and more like someone had just firebombed the path forward.
Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable.
The angst of facing mortality has no remedy in probability.
After so many years of living with death, I’d come to understand that the easiest death wasn’t necessarily the best.
Shouldn’t terminal illness, then, be the perfect gift to that young man who had wanted to understand death? What better way to understand it than to live it? But I’d had no idea how hard it would be, how much terrain I would have to explore, map, settle.
The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language.
And so it was literature that brought me back to life during this time.
The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.